9: The Maintenance Phase of Care

CHAPTER 9

The Maintenance Phase of Care

Samuel Paul Nesbit

CHAPTER OUTLINE

Posttreatment Assessment

Objectives for the Posttreatment Assessment
Elements of the Posttreatment Assessment
Documenting the Posttreatment Assessment
Rationale for Including a Maintenance Phase in the Treatment Plan

Unresolved Issues
Follow-up of Untreated Diagnoses
Monitoring Chronic Conditions That Can Affect Oral Health
Revisiting Elective Treatment Issues
Patient-Based Issues
Rapport Building
Patient Education
Emphasis on Individualized Care
Health Promotion and Disease Prevention
Anticipating Further Treatment Needs
Practice Management Issues
Professional Competence
Efficient Delivery of Care
Reducing Patient Emergencies
Partnering With Patients
Issues Typically Included in the Maintenance Phase

General Health Considerations
Oral Self-Care Instructions
Oral Prophylaxis
Caries Control
Restorations and Prostheses
Periodontal Maintenance
Endodontic Reevaluation
Management of Chronic Oral Soft Tissue Disease
Management of Radiographically Evident Hard Tissue Abnormalities (Other Than Caries or Periodontal Disease)
Orthodontic Assessment by the General Dentist
Ongoing Orthodontic Treatment by an Orthodontist
Ongoing Orthodontic Treatment by the Patient’s Regular General Dentist
Orthodontic Treatment Has Been Completed
Radiographic Images
Elective Treatment
Documenting the Maintenance Phase Plan

The Periodic Visit
Evaluation
Update of the Health History Questionnaire
Vital Signs (Blood Pressure and Pulse)
Head, Face, and Neck/Extraoral/Intraoral Examination
Evaluation of any Patient Concerns or Complaints
Orthodontic/Occlusal/Temporomandibular Joint Examination
Periodontal Evaluation
Caries/Restorative Evaluation
Radiographic Images
Special Considerations for Implants
Special Considerations for Fixed Partial Dentures
Special Considerations for Removable Prostheses
Therapy
Progress Note
Conclusion

After completion of definitive phase therapy there will be remaining issues that must be addressed and rendered treatment that must be reevaluated. Some of these concerns will need attention for as long as the dentist-patient therapeutic relationship exists. In addition to their importance to patient care, good maintenance phase plans provide the patient-specific elements essential to the development of an organized, practicewide system of periodic care that serves as the backbone of a successful and productive dental practice.

Although this aspect of the treatment plan may seem less important at the outset, the maintenance phase represents a critical component of any complex treatment plan. In many cases, the long-term success or failure of the plan depends on it. As this chapter unfolds, it will become clear why the dentist should discuss long-term periodic care with the comprehensive care patient. Furthermore the rationale for initiating this discussion when the original treatment plan is presented will also become apparent.

Prevention of future problems is, of course, the guiding principle of the maintenance phase. The astute practitioner works throughout all phases of treatment to educate the patient in strategies for maintaining a healthy oral condition and preventing future oral disease. Certain aspects of a systemic phase may include activities that are preventive in nature. The acute phase may include treatment that has the effect of preventing disease progression. The disease control phase, by its nature, is preventive in orientation, and numerous references to preventive therapies are made in Chapter 7. Nevertheless, significant patient education and the reinforcement of earlier oral hygiene instruction occur primarily during maintenance phase visits. For that reason, preventive concepts and preventive therapy are emphasized in this chapter. The reader is reminded that it would be shortsighted and inappropriate for the practitioner to make prevention primarily the hygienist’s responsibility and to attend to it exclusively in the maintenance phase. Prevention must be the responsibility of the entire dental team and must be carried out throughout the treatment process.

 

Dental Team Focus

The Oral Health Team and the Maintenance Phase of Treatment

The maintenance phase of the patient’s care is an ongoing process during which all members of the oral health team share in the same philosophy and treatment goals.

The role of the administrative staff includes:

• Keeping dental records up to date
• Adding any health history updates and medical alerts to the patient record
• Placing patients on a regularly scheduled preventive recall system
• Scheduling patients for untreated conditions
• Sending postcards, calling, or messaging to confirm appointments

The dental assistant’s role includes:

• Documenting the posttreatment assessment
• Communicating and advocating for the practice by actively listening to and responding to the patient’s questions and concerns
• Charting and documenting findings from the periodic visit
• Exposing and processing prescribed radiographs
• Assisting in restorative or specialized procedures that are identified at a periodic visit

The dental hygienist will carry a substantial responsibility for patient care through this phase. Those responsibilities include:

• Building rapport with the patient, ensuring continuity of care, and helping the patient to establish and maintain a long-term positive relationship with the practice
• Through nutritional guidance, educating patients on achieving better health
• Reemphasizing oral hygiene instructions and disease control measures
• Performing the periodic examination
• Performing a dental prophylaxis and scaling and root planing on a regularly scheduled basis
• Identifying issues and problems that may need management or treatment
• Answering questions and providing guidance concerning elective procedures

The maintenance phase must be flexible and individualized, with timing and content specifically tailored to each patient’s needs. Although formulated at the treatment planning stage, it will have been modified during the disease control and definitive treatment phases, and will take its final form at the posttreatment assessment, which is discussed in the following section. The dentist implements maintenance phase care through the periodic visit discussed in the final section of this chapter. The term periodic visit or recare visit is preferred to recall visit, which suggests that something is defective and needs to be corrected. In contrast, maintenance services should by their very nature be timed and directed to accommodate the individual patient’s needs. The American Dental Association (ADA) sanctioned procedure coding system uses the designation “Periodic Oral Evaluation.” Consistent with that perspective, the terms “periodic examination” and “periodic visit” are used in this text.

POSTTREATMENT ASSESSMENT

The posttreatment assessment is a dedicated, structured appointment scheduled at the conclusion of the disease control phase of treatment, if the original plan includes disease control, and at the conclusion of the definitive phase. The purposes of the appointment are to assess the patient’s response to treatment, comprehensively evaluate current oral health status, determine any new treatment needs, and develop a specific plan for future treatment. If accomplished during the first periodic evaluation and visit, the posttreatment assessment includes oral health instruction, selected scaling, and oral prophylaxis.

Most colleges of dentistry have developed a formalized process for a clinical examination when the patient is about to exit the patient care program. This discussion uses one such system as an example. Because each practice or institution has unique needs, the decision regarding development of a posttreatment assessment protocol is made on an individual basis. Whatever mechanism the dentist decides on, the emphasis here is on the importance of engaging the patient in a comprehensive reevaluation and reassessment at the conclusion of the disease control phase of treatment and/or at the conclusion of the entire plan of care. Many practitioners prefer not to formalize this process, declining to take the time to develop a specific protocol or form for recording findings. Certainly the current standard of care in practice does not dictate a mandatory posttreatment assessment protocol. The standard of care does require, however, that patients be provided maintenance services and continuity of care. In that context, the concepts described here should have application to any practice. Each practitioner is encouraged to incorporate some type of patient maintenance program into the office policy manual and to implement use of that program with each patient. If the reader does choose to develop a formal posttreatment assessment protocol, the information included here can be used as a guide for that purpose.

Objectives for the Posttreatment Assessment

The purpose and intent of the posttreatment assessment is to enable the practitioner to evaluate the following:

• The patient’s present oral condition
• Outcomes from treatment rendered by the dental team
• The patient’s satisfaction with the care that has been provided
• Present and future treatment needs of the patient

The posttreatment assessment provides a foundation for planning any additional treatment and maintenance therapy the patient will need.

Elements of the Posttreatment Assessment

Items to be included in the posttreatment assessment and recorded in the patient record vary with the nature and scope of the dental practice, the individual patient profile, and need. Typical elements in a posttreatment assessment are as follows:

• Update of the general health history and review of systems
• Recording vital signs
• A head/face/neck examination to reassess any previously diagnosed conditions and to determine whether any new oral pathology is present
• Updating radiographs according to the practice or institutional protocol and the patient’s individual need
• Evaluation of the alignment of the teeth and jaws; the occlusion; the temporomandibular joint; and the patient’s ability to speak, chew, and function
• Assessment of all periapical areas, with particular focus on teeth that have received root canal therapy
• Comprehensive periodontal assessment
• Evaluation of all existing restorations and prostheses
• Comprehensive caries assessment
• Statement regarding the patient’s satisfaction (or dissatisfaction) with the treatment rendered; were all the patient’s expectations met?
• Summary of the patient’s response to treatment; was the patient compliant with attendance and professional recommendations?
• Description of any remaining restorative needs and how those needs will be addressed
• Specific plan to address any current or future problems

Documenting the Posttreatment Assessment

The posttreatment assessment may be documented in the progress notes in a narrative or bullet format, with or without a predetermined outline to guide the process. If the practice has multiple providers, a common outline or format should be developed for consistency and efficiency. In an institutional setting, it is usually advantageous to develop a form specifically for that purpose (Figure 9-1).

image

Figure 9-1 Posttreatment assessment record form.

RATIONALE FOR INCLUDING A MAINTENANCE PHASE IN THE TREATMENT PLAN

The primary purpose of the maintenance phase is to ensure long-term oral health, optimum function, and favorable esthetics for the patient. In the maintenance phase, continuing systemic issues can be managed; disease control measures can be reevaluated and strengthened; and restorations and prostheses can be repaired, cleaned, polished, recontoured, or relined as needed. Success or failure of previous treatment must be reassessed and any necessary additional treatment planned. Multiple benefits derive from a comprehensive and strategically crafted plan for the maintenance phase. These benefits can be clustered into three categories: (1) issues that remain unresolved at the close of the definitive phase of treatment, (2) patient-based issues, and (3) practice management issues.

Unresolved Issues

Follow-up of Untreated Diagnoses

At the conclusion of the definitive treatment phase, previously diagnosed but untreated conditions may require reevaluation. These might include reactive soft tissue lesions, asymptomatic chronic bone lesions, defective but not problematic restorations, or teeth with potential carious lesions. The maintenance phase provides an ideal time to reassess these issues, discuss them with the patient, and develop consensus for a long-term strategy that addresses these issues.

Monitoring Chronic Conditions That Can Affect Oral Health

Such conditions might include chronic oral disseases such as periodontal disease; systemic diseases with significant oral manifestations such as Sjögren’s syndrome (Figure 9-2); or systemic diseases that influence plans for or the delivery of dental treatment. The maintenance phase provides an opportunity to reassess these conditions, determine if new intervention or re-treatment is warranted, and deal with any new sequelae or related conditions that have arisen.

image

Figure 9-2 Examples of the relationship between systemic and oral disease. A, Oral changes associated with cyclic neutropenia. B, Parotid enlargement in a diabetic patient. C, NUG in a patient with HIV infection. (Courtesy Dr. V. Murrah, Chapel Hill, NC.)

Revisiting Elective Treatment Issues

Earlier in the course of treatment, patients may have had dental concerns or aspirations that for many reasons (including time, finances, or anxiety) they chose to defer. Similarly, the patient earlier may have declined certain elective treatments that the dentist recommended, such as removal of asymptomatic third molars or replacement of missing teeth. The maintenance phase provides an ideal opportunity to revisit these issues.

Patient-Based Issues

Rapport Building

Patients return to their dentists for periodic care for many reasons beyond the obvious recommended scaling and oral prophylaxis. The importance of the professional trust and faith that patients place in their dentists and the personal security obtained from the relationship should not be underestimated or taken for granted. Consciously or unconsciously, most patients have a strong expectation that their dentist is diligently looking out for their best interests and will do what is best to promote and ensure their oral health. Periodic visits do much to cement the relationship and fulfill the patient’s expectations.

Patient Education

The maintenance phase serves as an effective instrument to educate and motivate the patient, and helps maintain the patient’s awareness of the importance of continuing attention to oral health. As the dentist plans the maintenance phase and shares that information with the patient, the patient has the opportunity to learn about the nature and the importance of this aspect of the plan of care and to raise questions about it. As the dentist explains the need for maintenance therapy and the ways in which the periodic visits form an integrated part of the overall plan of care, the patient comes to appreciate how this phase of treatment affects his or her future oral health.

More specifically, discussing the maintenance phase helps educate the patient about the details of care provided during the periodic visits and the patient’s own contribution to maintaining a healthy oral condition. This is the ideal opportunity to inform the patient about oral self-care practices that help preserve restorations and prostheses, maintain a disease-free environment, and prevent future problems. Suggestions to the patient may be given orally, in written form, or using pamphlets or audiovisual materials.

Writing the maintenance phase into the treatment plan reminds the patient of its presence and importance each time he or she picks up a copy of the plan of care. It also reminds the patient of specific tasks and expectations that are his or her responsibility. That knowledge becomes a powerful tool for the dentist in ongoing attempts to instill a sense of responsibility in the patient and to reinforce the patient’s appreciation of the need to maintain a long-term therapeutic relationship.

Emphasis on Individualized Care

Although patients may be unsophisticated in their understanding of dental disease or the finer elements of dental treatment, they quickly develop a sense of how a dental practice functions and share that information with their friends and neighbors. Patients may more easily characterize office policy concerning periodic visits than the dentist can. Is the standard a routine “6 months’ checkup and cleaning”? Or is there an individually planned interval with a specified structure tailored to the needs of the individual patient? In the all-too-common first situation, patients may gain the impression that production rather than individualized patient care is the motivating influence.

Arguably one of the greatest rewards in dentistry comes from the satisfaction of seeing long-term patients maintain a healthy, esthetic, and functional oral condition. For the dentist, recognizing his or her role in that process and the patient’s appreciation of that role are rich rewards. These same patients are the best referral sources and can ensure that the practice is sustained for as long as the dentist wishes it to be. Taking the time to develop and carry out a comprehensive and individualized maintenance phase for each patient ensures good patient care. It also can provide enormous benefits to staff, the practice, and the dentist.

Health Promotion and Disease Prevention

Unfortunately, some patients only think of seeing the dentist when a problem develops. Because the well-constructed maintenance phase places the emphasis on promoting and sustaining optimal oral health and function, rather than on the restoration and reconstruction resulting from past disease, this phase makes clear the role of dentistry as a health care profession.

Anticipating Further Treatment Needs

A thoughtful, comprehensive maintenance phase plan includes any issues that realistically can be expected to need reevaluation, reconsideration, or re-treatment in the future. Specific notes, such as “reevaluate tooth #29 with poor periodontal prognosis” or “reassess patient need and/or desire for crown on tooth #19 with compromised cusp integrity,” confirm that the patient has been alerted to the possible risks and hazards and clearly puts the responsibility for accepting the consequences of deferring treatment on the patient rather than the dentist. A casual review of the original treatment plan (or progress note if written there) quickly brings the issue to the patient’s attention again.

Without a clearly stated maintenance phase, patients may assume that any new problems that arise are at least in part the responsibility of the dentist. The tooth with long-standing severe periodontitis that now must be extracted or the tooth with a large amalgam restoration that now fractures are examples. Recording these potential problems in the treatment plan and calling them to the patient’s attention at the outset of the maintenance phase avoids any potential for doubt, misunderstanding, mistrust, or conflict.

Practice Management Issues

Professional Competence

Collectively the entire patient record if it includes a comprehensive, accurate, and complete database, diagnosis, plan of care, and consent provides excellent evidence of professional competence. A thorough, well-written maintenance phase, although not indispensable in this regard, certainly contributes to a positive view of professional competence and may help discourage a disgruntled patient from pursuing litigation.

Efficient Delivery of Care

A well-written maintenance phase plan of care can be used as an effective tool to alert office staff, dental assistants, hygienists, and the dentist to the particular systemic or oral health issues or other concerns that should be addressed during periodic visits. Awareness of those issues at the outset makes the visit more focused, efficient, and personalized. The patient’s individual needs can be considered immediately without requiring the dentist to sort through the chart, looking at multiple progress notes to reconstruct the history. With a recorded plan, the entire staff approaches the periodic visit proactively, confidently, and efficiently.

Reducing Patient Emergencies

An informed patient who expects and anticipates problems is more likely to take preventive action before a crisis develops, is less likely to need emergency care, is more apt to have a realistic understanding of a problem (and be able to discuss it rationally), and is more apt to accept recommended treatment. For the dentist and the staff, this translates into fewer interruptions, less anxiety for the patient, reduced staff stress, and smoother patient flow. Such a practice usually provides a more patient-friendly, enjoyable, and rewarding setting in which to work.

Partnering With Patients

The maintenance plan encourages the patient to become a partner in the long-term management of his or her oral health, rather than simply a consumer of dental goods and services. The maintenance phase, by design and necessity, engages the patient in the process. Although many patients remain quite comfortable in the traditional model of dental care in which the dentist makes all the decisions, such an approach places all the responsibility for the success of treatment on the shoulders of the dentist, fostering an overly dependent patient-dentist relationship. The maintenance phase provides an effective way to appropriately delineate roles and responsibilities for the patient’s long-term oral health.

ISSUES TYPICALLY INCLUDED IN THE MAINTENANCE PHASE

To list all the items that could be included in the maintenance phase would be a large undertaking. To give the reader a realistic perspective on this issue, the authors suggest the following list of categories that might be included. The list is not all-inclusive, but is representative and may serve as a menu or template from which each practitioner may begin to develop a selection list appropriate for his or her own practice. Although no individual patient would be expected to require attention to all of the areas listed here, it can be anticipated that most patients will need several.

Only gold members can continue reading. Log In or Register to continue

Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 9: The Maintenance Phase of Care
Premium Wordpress Themes by UFO Themes